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Claims Form

    Please fill in the below form to the best of your knowledge. Questions marked with an "*" are mandatory.

    Primary Contact Details

    Please provide the contact details for the best person to discuss the claims with.

    Primary Contact Name:

    Primary Contact Number:

    Primary Contact Email:

    Policy Holder: *

    Initial Questions

    Was the incident a vehicle theft? *

    Does the third party Claim relate to a Motor Vehicle/ Property or Both? *

    Were there any injured parties? *

    Were there any witness’s? *

    Were the Police notified? *

    Driver of policyholder's vehicle (or last in charge) - Part 1 of 9

    Full Name: *

    Date of Birth: *

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Phone Number: *

    Occupation: *

    Vehicle being used with Policyholder’s permission?: *

    Agency Driver?: *

    Have you had any accident, loss (incl. fire or theft) or claim in the last 3 years?: *

    If yes, give details:

    Give details of any disease, condition, physical / mental infirmity, defective of vision / hearing – that may impair driving ability. *

    Policyholder's vehicle - Part 2 of 9

    Make: *

    Model: *

    Registration Number: *

    Gross Vehicle Weight: *

    Number of passengers: *

    Trailer attached? *

    Vehicle still in use? *

    Do you have photos of the damage? *

    If so, please email or text over any supporting imagery.

    For what purpose was the vehicle being used: *

    Damage sustained in this incident: *

    Where is the vehicle now - Location & Contact Number: *

    Incident details - Part 3 of 9

    Date of Incident: *

    Time of Incident: *

    Speed of Vehicles:

    - Yours (mph): *

    - Others (mph): *

    Speed Limit (mph): *

    Location of Incident: *

    Circumstances of Incident - Part 4 of 9

    Please explain in full and to the best of your knowledge how the incident happened, details of all the property damage sustained and If necessary, please also provide a sketch of the incident to include the width of the roads, type and position of all road signs and markings, direction of travel of all parties and the points of impact(s). *

    Is the insured driver fully to blame for this incident? *

    If “No” why not?

    Other parties Motor Vehicle - Part 5 of 9

    Other Parties Full Name: *

    Did you obtain 3rd parties address? *

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Number of Passengers: *

    Vehicle Make: *

    Vehicle Model: *

    Colour of vehicle: *

    Registration Number: *

    Were seat belts fitted to all vehicles? *

    If ‘Yes’ were they in use at the time of the accident?

    Damage to vehicle/Point of impact: *

    Do you have photos of the damage? *

    If so, please email or text over any supporting imagery.

    Other Party Insurers: *

    Policy Number: *

    Property damage - Part 6 of 9

    Name: *

    Telephone Number: *

    Did you obtain the property address?

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Extent of Damage: *

    Do you have photos of the damage? *

    If so, please email or text over any supporting imagery.

    Injured Parties - Part 7 of 9

    Was the person injured...

    Name: *

    Did you obtain the person's injured address?

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Nature & Extent of Apparent Injuries: *

    Taken to Hospital: *

    Name of Hospital: *

    Would you like to add another injured party?:

    Injured Party 2 - Part 7 of 9

    Was the person injured...

    Name: *

    Did you obtain the person's injured address?

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Nature & Extent of Apparent Injuries: *

    Taken to Hospital: *

    Name of Hospital: *

    Would you like to add another injured party?:

    Injured Party 3 - Part 7 of 9

    Was the person injured...

    Name: *

    Did you obtain the person's injured address?

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Nature & Extent of Apparent Injuries: *

    Taken to Hospital: *

    Name of Hospital: *

    Would you like to add another injured party?:

    Injured Party 4 - Part 7 of 9

    Was the person injured...

    Name: *

    Did you obtain the person's injured address?

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Nature & Extent of Apparent Injuries: *

    Taken to Hospital: *

    Name of Hospital: *

    Would you like to add another injured party?:

    Injured Party 5 - Part 7 of 9

    Was the person injured...

    Name: *

    Did you obtain the person's injured address?

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Nature & Extent of Apparent Injuries: *

    Taken to Hospital: *

    Name of Hospital: *

    Witnesses - Part 8 of 9

    Name: *

    Did you obtain the witnesses address? *

    Address Line 1: *

    Address Line 2: *

    City: *

    Postcode: *

    Telephone Number: *

    Police - Part 9 of 9

    Did the police take details of the incident? *

    If ‘’Yes’’ please give details below:

    Officer’s Name *

    Officer’s Number: *

    Did you obtain the station address? *

    Station Address: *

    Did you make a written statement? *

    Was anybody cautioned? *

    If ‘’Yes’’ please give details below:

    Name of person submitting the form:

    I declare that to the best of my knowledge and belief the details given are true. I understand that if fraudulent means including inflation or exaggeration of the claims are used, all benefit under the Policy shall be forfeited and criminal proceedings may ensue. If the vehicle is beyond repair, I authorise removal to safe storage, subject to Policy Cover. I authorise you/your solicitors on my behalf to make enquiries/admissions/settlements as considered necessary for the disposal of such claims and litigation arising. I authorise the release of my DVLA records. I understand you may seek information from other Insurers to check the answers I have provided.

    Insurers pass information to the claims and Underwriting Exchange Register, run by Insurance Database Services Ltd (IDS Ltd) and the Motor Insurance Anti-Fraud and Theft Register, run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also to prevent fraudulent claims. Under the conditions of your policy, you must tell us about any incident (such as an accident or theft) which may or may not give rise to a claim. We will pass information relating to this incident to the registers.